1
Q
Sodium Valproate - Risks in Pregnancy
A
- Risk of foetal birth defect (mainly neural tube) 1:100
- Advise to stop and monitor mood
2
Q
BPAD in Pregnancy - Mania
A
- Haloperidol (SEs: tremors and rigidity) and Olanzapine (SEs: weight gain and sedation) treatments of choice
- ECT indicated if antipsychotics fail
3
Q
BPAD in Pregnancy - Depression
A
- CBT for moderate bipolar depression
- Fluoxetine safest AD for pregnancy - suitable if depression severe and few previous manic episodes
4
Q
BPAD in Pregnancy - Lithium
A
- Risk of Ebstein’s anomaly 0.05-0.1% if exposed in first trimester
- If continued needs level 2 USS at 6 and 18 weeks gestation
5
Q
Post-Natal Depression/Psychosis - Risk Factors Assessment
A
- Any personal or family psychiatric history?
- Pregnancy planned?
- First child? If not age gap?
- How was pregnancy and delivery?
- Any complications?
- Did the baby need any hospital treatment?
- How is relationship with husband? Supportive?
- Other support around you?
- Have you been able to bond with you baby?
- Are you breastfeeding?
6
Q
Postnatal Depression/Psychosis - Risk
A
- Any thoughts of harming yourself?
- Any thoughts of harming baby?
- Any neglect or physical abuse?
- Where is the baby now?
7
Q
Post-Natal Psychosis - Assessment Questions
A
- Worried someone is trying to harm you or your baby?
- How certain?
- Worried something is wrong with your baby?
- Have you had mood swings?
- Have you been confused about time, place and person?
- Have you heard any voices since delivery?
- Do they give you instructions? To harm baby?
- Do you feel someone else can control how you think, act or feel?
8
Q
Postnatal Psychosis - Management
A
- Manage based on risk but admission to hospital - preferably mother and baby unit usually indicated.
- Should have a nurse dedicated to care and supervision of child and lockable nursery
- Mother-baby interactions monitored
- Screen to rule out organic causes e.g. thyroid
- Antipsychotics for psychotic symptoms - sulpride and olanzapine best for breastfeeding
- Lithium good for mania but incompatible with breastfeeding
- ECT if drug treatment fails - very effective in psychosis
9
Q
Lithium and Pregnancy - Risks
A
- Increased risk of heart abnormality called Ebstein’s - increase 10-20x normal although still only 1/1000, risk greatest in weeks 2-6.
- Li usually safe after 26 weeks but can cause issues wieh neonatal lethargy, hypotonia, arryhtmias and goitre.
10
Q
Lithium In Pregnancy - Continuation
A
- Lithium continued if needed - risk of relapse if mood stable and stopped 70% perinatally
- If continued would need extra USS at 2, 6 and 18 weeks.
- Regular U+Es. Li levels monthly then weekly after 36 weeks and within 24 hours of birth.
11
Q
Drug Use In Pregnancy - Assessment of drug use
A
- What current drugs are you using?
- Heroin, cannabis, cocaine, ecstasy, sleeping tablets
- If using daily dependency criterion:
- Do you find yourself craving the drug
- Have you found you need more to have the same effect?
- Do you get withdrawal symptoms if you stop using it?
- (Heroin = muscle aches, stomach cramps, nausea, yawning, rhinnorhea)
- Are you preoccupied with taking the drug all the time?
- Alcohol?
- Smoking?
12
Q
Drug Use In Pregnancy - Assessment of Heroin Use
A
- Which route do you take heroin? Smoking or injecting?
- If injecting sharing needles?
- How much do you use on a typical day? How often?
- How much do you spend? How do you get the money?
- Have you been taking methadone? what dose?
13
Q
Drug Use In Pregnancy - Assessment of Pregnancy Circumstances/Risk
A
- Have you confirmed you are pregnant? How?
- Is this planned or unplanned?
- How do you feel about being pregnant?
- Who is at home with you?
- Do you have any other children? Where are they?
- How is your relationship with your partner?
- Are they supportive?
- Do they also use drugs?
- What is your financial situation like?
14
Q
Drug Use In Pregnancy - Heroin Use Management Initial
A
- Physical examination - nutritional status and needle marks
- Confirm pregnancy
- Bloods including BBV screen
- STD screen
- Aim is to stabilise heroin intake and introduce methadone substition under methadone treatment program - will need admission
- Also education about harm reduction - safe injecting
- Optimise nutrition with folate and iron tablets
- MDT care - drugs and alcohol service, obstretician, neonatologist, anaethetist, social services
- Other substances:
- Cocaine, cannabis and amphetamines stop
- Alcohol detox
- Benzos - lowest dose.
15
Q
Drug Use In Pregnancy - Heroin/Methadone Detox
A
- Detox not recommended in first trimester due to risk of sponteaneous abortion
- In second trimester detox can be safely undertaken with methdone over a 4 week period under care of addiction specialist and obstretician
- Afterwards needs MDT support from psychiatrist, drug prevention workers, psychologist and social worker to prevent relapse
- If methadone continued into third trimester needs increased dose towards end of pregnancy and divided doses to prevent withdrawal
16
Q
Drug Use In Pregnancy - Heroin Use and Delivery
A
- Anaesthetist will need to review before delivery to consider analgesic requirements based on methadone dose used
- Babies at risk of neonatal abstinence syndrome - on delivery both mother and baby will be taken to a special mother and baby unit to be treated
- Vomiting and diarrhoea
- Irritability
- Feeding problems
- Fever
- Increased muscle tone
- Hyperreflexia
*
17
Q
Drug Use In Pregnancy - Heroin Post-Natally
A
- Methadone compatible with breast-feeding although dose should be <20mg/day
- Post-natal ongoing monitoring of mental state of mother, decisions about detox vs. harm minimisation, child protection and support plans.
18
Q
Postnatal Depression - Management
A
- Mild - non-directive counselling, CBT, IPT, self-help and mother and baby groups
- Moderate - SSRIs, compatible with breastfeeding
- Signficiant - consider admission to mother and baby unit - risk to child if suicidal
- ECT may be required
19
Q
Postnatal Psychosis - Aftercare/Prognosis
A
- Check mother-baby interaction before discharge.
- Close support after discharge from hospital
- Cases usually settled within 6 weeks, most fully recovered within 6 months, few protracted
- After one episodes risk for further episode in next pregnancy between 1/3 to 1/5.
20
Q
Maudsley Advice Drug Choice with Breastfeeding - BPAD
A
- Valproate safe for breastfeeding but mother needs to be on contraception
- Lithium contraindicated as excreted into breastmilk and can be toxic to baby
21
Q
Maudsley Advice Drug Choice with Breastfeeding - Depression
A
- Paroxetine and Sertraline SSRIs of choice
- TCAs present in breast milk but at low levels
22
Q
Maudsley Advice Drug Choice with Breastfeeding - Schizophrenia
A
- Olanzapine and sulpride antipsychotics of choice
23
Q
Maudsley Advice Drug Choice with Breastfeeding - Anxiety and Insomnia
A
- Lorazepam for anxiety
- Zolpidem for insomnia
- Advise mother not to sleep with newborn due to risk of accidental suffocation
24
Q
Post-Partum Psychosis - Clinical Features
A
- Sudden onset, usually in first 2 weeks postpartum, can be after 6
- Marked perplexity but not cognitively impaired
- Rapid fluctuation in mental state
- Marked restlessness, fear and insomnia
- Delusions, hallucinations, disturbed behaviour develop rapidly
- 80% are affective in nature
25
Post-Partum Psychosis - Incidence and Risk Factors and Prognosis
* 1:500 mothers
* n patients with BPAD post-partum psychosis develops in 20-30% of cases
* Other RF:
* Increased rate of C-section
* Higher social class
* First birth
* Higher social class
26
Postnatal Depression - Incidence, Prognosis, Risk Factors
* PND affects up to 1 in 10
* Usually within a month but can be up to 6 months later.
* Edinburgh Postnatal Depression Scale can be used by health visitors to screen for in new mothers.
* Risk factors – single, older, C- section, premature, unsupported, PPHx/FHx depression.
* 70% recover
CASC
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